Recent Complication

[Noyac]

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Thanks for bringing that up, I meant to address disposable manometer devices ...

The case is still being reviewed and a formal RCA is going to be done. At this point, the two things I'll probably formally recommend are
- standardized printed postop instructions for all nerve block patients
- routine use of such an injection pressure monitoring device

Again I don't think the injury was caused by the injection itself so the use of an injection manometer wouldn't have prevented this injury IMO - but there doesn't seem to be much of a down side to using one, other than cost. Retail price for the BSmart is about $10 per unit.

Anyone have firsthand experience with the BSmart or other brands?

I would be hesitant to require this for all. I would leave it out and just verbally recommend it to everyone. If you put it in writing a few things can happen:
-You piss off people by making them change their practice to something without any proven benefit.
-what happens if they are out of stock? You have it in writing that they need to be used.
-you are adding cost without any evidence of benefit

 

[Noyac]

Accidental intravascular administration of particulate steroids.

The non PF deca is the IV stuff we use everyday, right?

 

[sevoflurane]

Yep. Non-PF decadron still dissolves in LA.

Anhydrous depo-medrol doesn't dissolve in LA.

 

[pgg]

I agree. I never take .4mA, especially with a good USD view. If I'm getting a patellar snap @ .6mA and I know I'm where I need to be with my needle via USD (especially if I'm UNDER the femoral nerve), I see NO advantage of pushing the needle deeper.

I see this as a great safety mechanism of USD nerve blocks.... I don't care what the literature says.

If you are watching the LA spread under u/s and injection pressure is low, the odds of it being an intraneural injection have got to be about zero.

I can't say I really agree that 0.4 mA is unreasonable. NYSORA quotes 0.2 - 0.5 mA as acceptable. Barash quotes 0.3 - 0.5.

Nerve stim only, I've had failed blocks at 0.6 so I aim for 0.4 but no lower than 0.3. I also rely on easy injection (subjective).

I am a big fan of u/s and use it when I can. But nerve stim only, to 0.4 mA, has a pretty solid track record.



I quit adding epi to any of my blocks a long time ago. I was starting to like Decadron, but for some reason the only thing the hospital stocks now has preservative in it. Still waiting on the pharmacy to get back to me on that.

 

[pgg]

I would be hesitant to require this for all. I would leave it out and just verbally recommend it to everyone. If you put it in writing a few things can happen:
-You piss off people by making them change their practice to something without any proven benefit.
-what happens if they are out of stock? You have it in writing that they need to be used.
-you are adding cost without any evidence of benefit

These are good points.

The non PF deca is the IV stuff we use everyday, right?

Our IV decadron vials don't say anything about containing a preservative on them. I had to go the pharmacy and ask them to dig up a box to confirm that they weren't PF.

 

[sevoflurane]

Anhydrous depo medrol when mixed with LA looks like this:

 

[sevoflurane]

If you are watching the LA spread under u/s and injection pressure is low, the odds of it being an intraneural injection have got to be about zero.

I can't say I really agree that 0.4 mA is unreasonable. NYSORA quotes 0.2 - 0.5 mA as acceptable. Barash quotes 0.3 - 0.5.

Nerve stim only, I've had failed blocks at 0.6 so I aim for 0.4 but no lower than 0.3. I also rely on easy injection (subjective).

I am a big fan of u/s and use it when I can. But nerve stim only, to 0.4 mA, has a pretty solid track record.



I quit adding epi to any of my blocks a long time ago. I was starting to like Decadron, but for some reason the only thing the hospital stocks now has preservative in it. Still waiting on the pharmacy to get back to me on that.

I know NYSORA states .2-.5mA

I absolutely disagree with them.

.2mA is really not smart, unecessary and then you have to document that amperage.

My personal choice is around .5mA.

I might take above .45mA, but i'f I'm at .4mA I'm backing off. Risk/benefit in regards to my malpractice. I've never had .5mA fail me.

 

[Noyac]

So what's the issue with using decadron with preservative? We give it IV all the time. We are not placing it intrathecally or epidurally.

I don't know the answer just to be clear.

 

[sevoflurane]

So what's the issue with using decadron with preservative? We give it IV all the time. We are not placing it intrathecally or epidurally.

I don't know the answer just to be clear.

It has not been investigated.... and ultimately it may not be of any consequence. All the studies that I know of use PF decadron... Some of my partners will use it if it's diluted in > 30cc's of LA.

Evidence?

There is none.

 

[Noyac]

It has not been investigated.... and ultimately it may not be of any consequence. All the studies that I know of use PF decadron... Some of my partners will use it if it's diluted in > 30cc's of LA.

Evidence?

There is none.

Dude, you and I we can take over this world of anesthesia. 😉

 

[pgg]

So what's the issue with using decadron with preservative? We give it IV all the time. We are not placing it intrathecally or epidurally.

I don't know the answer just to be clear.

Is a perineural injection really that much different than an epidural?


I have asked myself your question, and the only good answer I could come up with was fear of clouding the etiology of complications. Honestly I think it's a total non-issue ... less than a mL of additive diluted to 15 or 20 mL in PF local is not going to have enough preservative to kill any nerves.

But I don't want to have to try to convince a jury that the non-PF dexamethasone I negligently put in their nerve block didn't cause the injury. We're already off-label with using dexamethasone in nerve blocks at all, though there's good and growing safety data on it.

I think the preservative in dexamethasone is a benzyl alcohol or other alcohol something, can't remember.

"So doctor, you're aware that alcohol is used for palliative neurolytic blocks to destroy pain nerves in cancer patients, but you thought it was OK to inject alcohol next to my client's nerve?"

 

[periopdoc]

It doesn't happen often, but who here has done an ISB under USD that wouldn't stimulate...? Yet had a great picture? and then deposited your LA? and the patient woke up with a great block?

I have had this with ISB (rare), femoral (occasional), and sciatic (frequent). Not that I was trying hard to get a stim, just that I was working with attendings who required me to use stim with U/S. I would get the needle where I wanted it with U/s, find no/ minimal stim, inject with good perineural spread and great results.

The problem with the sciatic is that to get the right twitch, the needle needed to be right in the middle between the tibial and the cp nerves when at the level of the split. Not infrequently I would see the needle stuck through the CP to get the right twitch if the operator was doing a anatomy/ stim only "blind" block with me watching with U/S. This was less of an issue if the block was done more proximally.

If you are good with in-plane u/s, you know exactly where your tip is. Hell, I can even identify the orifice (separate from the tip) on u/s. Just don't fool yourself when you know that you don't have perfect alignment.

- pod

 

[Noyac]

I think the preservative in dexamethasone is a benzyl alcohol or other alcohol something, can't remember.

"So doctor, you're aware that alcohol is used for palliative neurolytic blocks to destroy pain nerves in cancer patients, but you thought it was OK to inject alcohol next to my client's nerve?"

I don't see benzoyl alcohol in here:

Each milliliter of DECADRON Phosphate injection, 4 mg/ mL, contains dexamethasone sodium phosphate equivalent to 4 mg dexamethasone phosphate or 3.33 mg dexamethasone. Inactive ingredients per mL: 8 mg creatinine, 10 mg sodium citrate, sodium hydroxide to adjust pH, and Water for Injection q.s., with 1 mg sodium bisulfite, 1.5 mg methylparaben, and 0.2 mg propylparaben added as preservatives.

 

[pgg]

.2mA is really not smart, unecessary and then you have to document that amperage.

My personal choice is around .5mA.

I might take above .45mA, but i'f I'm at .4mA I'm backing off. Risk/benefit in regards to my malpractice. I've never had .5mA fail me.

I agree that 0.2 is too low. But as long as we're talking about lack of evidence for risk of +P Decadron ... what evidence is there of risk at 0.4?


Of course the proof of a block is in the patient's (lack of) pain; I'm not questioning your success or .5 threshold. Just saying I aim a bit lower and don't see a compelling reason to change. (Though these are exactly the discussions I like about this forum, when I'm not endlessly arguing politics.)

 

[pgg]

I don't see benzoyl alcohol in here:

Each milliliter of DECADRON Phosphate injection, 4 mg/ mL, contains dexamethasone sodium phosphate equivalent to 4 mg dexamethasone phosphate or 3.33 mg dexamethasone. Inactive ingredients per mL: 8 mg creatinine, 10 mg sodium citrate, sodium hydroxide to adjust pH, and Water for Injection q.s., with 1 mg sodium bisulfite, 1.5 mg methylparaben, and 0.2 mg propylparaben added as preservatives.

It's listed as an ingredient here

Each mL contains dexamethasone sodium phosphate equivalent to dexamethasone phosphate 4 mg or dexamethasone 3.33 mg; benzyl alcohol 10 mg added as preservative; sodium citrate dihydrate 11 mg; sodium sulfite 1 mg as an antioxidant; Water for Injection q.s. Citric acid and/or sodium hydroxide may have been added for pH adjustment (7.0-8.5). Air in the container is displaced by nitrogen.

And I'm about 90% certain the stuff our pharmacy recently swapped in has benzyl alcohol in it. Kind of concerning that the only thing that tipped me off that we had a new formulation was that the color of the flip cap changed ... the vial labels DON'T mention preservative.

 

[sevoflurane]

I agree that 0.2 is too low. But as long as we're talking about lack of evidence for risk of +P Decadron ... what evidence is there of risk at 0.4?


Of course the proof of a block is in the patient's (lack of) pain; I'm not questioning your success or .5 threshold. Just saying I aim a bit lower and don't see a compelling reason to change. (Though these are exactly the discussions I like about this forum, when I'm not endlessly arguing politics.)

Personal preferance. That's all.
Tons of blocks are placed @.4mA everyday.

Just not mine.

 

[Noyac]

It appears tht decadron hasa a few different preservative concoctions. What color are the tops on yours. Mine are dark blue and occasionally we get some lighter blue ones.

 

[pgg]

It appears tht decadron hasa a few different preservative concoctions. What color are the tops on yours. Mine are dark blue and occasionally we get some lighter blue ones.

Ours are currently red 10 mg/mL. Used to have some blue ones, and before that our PF formulation had grayish/ brownish tops, might've been this manufacturer:

Pretty sure I've seen pink ones too.

 

[Frank Rizzo]

I would be hesitant to require this for all. I would leave it out and just verbally recommend it to everyone. If you put it in writing a few things can happen:
-You piss off people by making them change their practice to something without any proven benefit.
-what happens if they are out of stock? You have it in writing that they need to be used.
-you are adding cost without any evidence of benefit

I haven't been too impressed with the BSmart pressure monitors. The caveat being that I have only used them maybe 6-7 times. They just don't seem to be that accurate. It would stick, then suddenly jump up or down like the crappy monitor on your typical IV pressure bag.

Other block comments: i routinely stimulate to about .4 with and without u/s. Don't think going lower gets you anything. And yes, I still use both stim with u/s... I just like it better. Haven't gotten on the decadron bandwagon yet... some of our surgeons don't want blocks lasting that long, and I don't know if I necessarily do either, at least not for outpatients. I have drastically cut back my use of epi, and won't even think about it if the tourniquet is going to be anywhere near the site. I agree completely with whowever suggested low sciatic/high pops for TKRs, if they get one at all... they seem to work great while preserving some hammy function... all our morning TKR's are on their feet on the evening of POD #0. Obese, diabetic, or other things I don't like???... you're not getting a sciatic from me.

 

[BLADEMDA]

[FONT=Georgia, Times New Roman, Times, serif]
.​

[FONT=Georgia, Times New Roman, Times, serif]Can the information provided by BSmart™ be used to document a nerve block technique?.[FONT=Georgia, Times New Roman, Times, serif]YES. The information obtained by BSmart™ can be used to objectively document nerve block procedure.
.

• [FONT=Georgia, Times New Roman, Times, serif]Resistance to injection is a part of the standard documentation procedure during nerve blockade (1)..
• [FONT=Georgia, Times New Roman, Times, serif]The documentation requires clinicians to document whether the resistance to injection was "normal" or "high" and the course of action if it was abnormal.(1) .
• [FONT=Georgia, Times New Roman, Times, serif]In the past, documentation of the resistance was merely subjective and relied on the "learned feel" and experience of the clinician.
• [FONT=Georgia, Times New Roman, Times, serif]Objective monitoring can be used to allow trainees to acquire the appropriate "feel" or for less experienced personal to inject using the controllable force of injection.
• [FONT=Georgia, Times New Roman, Times, serif]A note in the chart stating that the injection pressure was <20 psi unambiguously indicates that the resistance (pressure) was paid attention to during the procedure..

[FONT=Georgia, Times New Roman, Times, serif]1. Reg Anesth Pain Med 2005;30:67-71.
.
​

 

[BLADEMDA]

I've never failed to get a twitch doing an ISB either with NS only or U/S plus NS. That said, with Diabetics I'm quite satisfied with a twitch of 0.8 or so. No failed blocks at 0.8 in elderly diabetics.

THe Popliteal block is a whole different animal. You won't always get a twitch here unless you place the needle inside the fatty tissue encasing the nerve. U/S is more reliable for Popliteal blocks because you only need to get close to the nerve. I must admit that my trusty Braun Stimulator isn't nearly as uselful as U/S doing a Popliteal block. You might as well not even bother with it.

Femoral blocks work well with the NS; you will get a twitch but sometimes the needle must be repositioned to a different part of the nerve. U/S only vs. NS only is "draw" here in my opinion.
Morbid Obesity is one condition where I really prefer U/S guidance for Femoral blocks.


we did not observe significant differences in block failures, patient satisfaction or incidence, and severity of postoperative neurological symptoms
http://www.anesthesia-analgesia.org/content/109/1/265.short

 

[BLADEMDA]

 

[dhb]

I agree that 0.2 is too low. But as long as we're talking about lack of evidence for risk of +P Decadron ... what evidence is there of risk at 0.4?


Of course the proof of a block is in the patient's (lack of) pain; I'm not questioning your success or .5 threshold. Just saying I aim a bit lower and don't see a compelling reason to change. (Though these are exactly the discussions I like about this forum, when I'm not endlessly arguing politics.)

http://journals.lww.com/anesthesiol...cal_or_Electrophysiologic_Evidence_of.25.aspx
Twenty patients undergoing popliteal block were enrolled; 17 patients completed the study protocol. After tibial nerve response was achieved by nerve stimulation (0.3–0.5 mA; 2 Hz; 0.1 ms)
Sixteen injections (94%, 95% CI: 71–100%) met criteria for an intraneural injection.

Not saying it's bad but using 0.3 to 0.5mA in the sciatic give you 95% chance of being intraneural. NS block have been done for years like this and have probably resulted in millions of intraneural injections (especially in the sciatic which has a high percentage of connective tissue) without evidence of serious injury.

 

[BLADEMDA]

However, an intraneural but extrafascicular injection may carry less risk for injury than an intraneural, intrafascicular injection. Mackinnon et al. suggested that the physical location of the injectant (intrafascicular vs. perifascicular) is a key factor that determines whether neurologic injury will result from an intraneural injection.16,17 Low incidence of complications after intraneural injections with SPB also may be attributable to the anatomic characteristics of the sciatic nerve in the popliteal fossa. The connective tissue of the sciatic nerve comprises as much as 80% of the cross-sectional area of the nerve, thus redirecting needles primarily through the path of lesser resistance (adipose tissue) rather than through more compact fascicles.18,19 For instance, needles deliberately inserted into sciatic nerves are more likely to pass between, rather than transverse, the fascicles.20 Two recent studies in animal models suggest that low-pressure injection is more likely to be associated with interfascicular, rather than intrafascicular, injection.8,9 In studies that reported intraneural injections without neurologic consequences, resistance to injection was judged to be normal.1–3,8

 

[cincincyreds]

All right I'll do my part and post a case. 🙂


Nothing crazy or esoteric. Just a simple case with a complication ... I was not the primary for the patient but was involved at various points.


Young, healthy ASA 1 patient here for an ACL repair with hamstring graft. We offer nerve blocks of one kind or another to all of our ACL repairs - usually no sciatic unless the repair is done with a hamstring graft. Sometimes they get femoral catheters and a take-home disposable pump depending on who's doing the case. This patient was offered single shot femoral and sciatic blocks (nerve stim techniques, no ultrasound).

Femoral block first, easy, 15 mL 0.5% ropivacaine + 2 mg preservative-free dexamethasone additive.

Sciatic block second, difficult. First person tries a classic approach, can't get it. I'm nearby, go to help, attempt an infragluteal approach, get nothing. First person tries again, eventually gets a good plantar flexion twitch at 0.4 mA. 25 mL 0.5% ropivacaine + 2 mg PF dexamethasone.

Patient gets an LMA for surgery. Tourniquet up at 300 mmHg for 107 minutes.

Wakes up, good blocks, no pain, goes home.

Telephone f/u on POD 1, he has some odd 4/10 "tightness" discomfort over his anterolateral lower leg. Knee pain is OK on oral meds. Hmm.

POD 2, he's in for evaluation. The femoral block is totally resolved. The sciatic block is resolved, except he has still has some painful numbness in the sural distribution and foot drop (2/5 motor strength with dorsiflexion of his foot).

A helpful person involved in the case 🙂 tells him he has nerve damage from the block.


What now? What do you tell the patient, any exam/study/referral you want? When?

I would tell the patient the problem is from the operation, not the block and would offer emg testing.

 

[EdPierce]

Most ridiculous post ever!

WHat do u find ridiculous? I find it pretty ridiculous about splitting hairs over how much voltage for ns ... Ns is super old school we don't even use them at my institution aside for lumbar plexus .. And the occasional obese interscalene ..our lumb plexus blocks are going out of style at my inst. and being replaced with us guided fascia Iliaca blocks for the exact reason of not knowing what ur putting your needle through .. I've seen some old timers do blocks under ns only ... Even femorals.. Get good twitch, inject local, pt still acts like they r in pain.. Hmmm why? Ur local is probably in the fascia aboe the nerve ..id just rather see what I am doing directly under us .. Sure no literature yet.. Like for a lot of things in anesthesia but it makes sense..l what's the downside? Training... Shocker that the old timers think its ridiculous .l you are probably doing crappy blocks and the pts don't know the difference...


I stand by my post.. Go pop fossa for knees not sub gluteal...it's safer and easier I and anytime u can use the ultrasound to make the procedure quicker and more precise.. God I'd prefer that to some ridiculous pressure monitor that looks like it came out in the seventies

 

[Apollyon]

WHat do u find ridiculous? I find it pretty ridiculous about splitting hairs over how much voltage for ns ... Ns is super old school we don't even use them at my institution aside for lumbar plexus .. And the occasional obese interscalene ..our lumb plexus blocks are going out of style at my inst. and being replaced with us guided fascia Iliaca blocks for the exact reason of not knowing what ur putting your needle through .. I've seen some old timers do blocks under ns only ... Even femorals.. Get good twitch, inject local, pt still acts like they r in pain.. Hmmm why? Ur local is probably in the fascia aboe the nerve ..id just rather see what I am doing directly under us .. Sure no literature yet.. Like for a lot of things in anesthesia but it makes sense..l what's the downside? Training... Shocker that the old timers think its ridiculous .l you are probably doing crappy blocks and the pts don't know the difference...


I stand by my post.. Go pop fossa for knees not sub gluteal...it's safer and easier I and anytime u can use the ultrasound to make the procedure quicker and more precise.. God I'd prefer that to some ridiculous pressure monitor that looks like it came out in the seventies

You, your, are, lumbar, institution. They're not difficult to spell out, and your argument doesn't seem like it's coming from someone who is young and/or not that smart. That is just some advice, to help your prose be more legible.

 

[BLADEMDA]

WHat do u find ridiculous? I find it pretty ridiculous about splitting hairs over how much voltage for ns ... Ns is super old school we don't even use them at my institution aside for lumbar plexus .. And the occasional obese interscalene ..our lumb plexus blocks are going out of style at my inst. and being replaced with us guided fascia Iliaca blocks for the exact reason of not knowing what ur putting your needle through .. I've seen some old timers do blocks under ns only ... Even femorals.. Get good twitch, inject local, pt still acts like they r in pain.. Hmmm why? Ur local is probably in the fascia aboe the nerve ..id just rather see what I am doing directly under us .. Sure no literature yet.. Like for a lot of things in anesthesia but it makes sense..l what's the downside? Training... Shocker that the old timers think its ridiculous .l you are probably doing crappy blocks and the pts don't know the difference...


I stand by my post.. Go pop fossa for knees not sub gluteal...it's safer and easier I and anytime u can use the ultrasound to make the procedure quicker and more precise.. God I'd prefer that to some ridiculous pressure monitor that looks like it came out in the seventies

You got balls. Not much for intelligence but balls

 

[periopdoc]

Ns is super old school we don't even use them at my institution aside for lumbar plexus .. And the occasional obese interscalene

Ever wonder why? I did. I asked. It is because non U/S guided blocks are harder to teach, harder to learn, and, in the hands of a trainee who is less than stellar at thinking, visualizing the anatomy, and listening to the instructor, less safe. On U/S the instructor can see exactly what the trainee is doing and can step in to minimize liability.

Read that carefully. I didn't say U/S is more safe or effective, just less risky when you are dealing with trainees of varying capabilities. The data is there and N/S vs U/S is equally safe and effective when comparing folks who are trained in both. I have some shame in saying that a N/S guided block is less safe in my hands than an U/S guided block. I was not well trained in the former, so I am handcuffed to the U/S. Much like the pulse-ox, U/S won't make much difference for those who trained without it, but for those of us who trained with it, we will need to continue to use it. Perhaps I should just cowboy up and go without, but I would feel more comfortable with someone watching over my shoulder.

Go pop fossa for knees not sub gluteal...it's safer and easier I and anytime u can use the ultrasound to make the procedure quicker and more precise.. God I'd prefer that to some ridiculous pressure monitor that looks like it came out in the seventies

You have literature for this? The pressure monitoring device is useful for all kinds of blocks including anatomic and U/S not just N/S.

- pod

 

[BLADEMDA]

Ever wonder why? I did. I asked. It is because non U/S guided blocks are harder to teach, harder to learn, and, in the hands of a trainee who is less than stellar at thinking, visualizing the anatomy, and listening to the instructor, less safe. On U/S the instructor can see exactly what the trainee is doing and can step in to minimize liability.

Read that carefully. I didn't say U/S is more safe or effective, just less risky when you are dealing with trainees of varying capabilities. The data is there and N/S vs U/S is equally safe and effective when comparing folks who are trained in both. I have some shame in saying that a N/S guided block is less safe in my hands than an U/S guided block. I was not well trained in the former, so I am handcuffed to the U/S. Much like the pulse-ox, U/S won't make much difference for those who trained without it, but for those of us who trained with it, we will need to continue to use it. Perhaps I should just cowboy up and go without, but I would feel more comfortable with someone watching over my shoulder.




You have literature for this? The pressure monitoring device is useful for all kinds of blocks including anatomic and U/S not just N/S.

- pod

There you go again using logic and peer reviewed evidence to make your points. Why bother? Guys like EdPierce know it all and shoot from the hip. After all he has decades of experience doing this doesnt't he?😉

It always amazes me how opinionated those in Medical School and Residency are about everything. I guess wisdom comes with age and experience

When I do a block (u/s or NS) I am much more concerned about complications than block success. The reason being is block success is pretty much expected no matter the technology being utilized.

 

[Noyac]

When I do a block (u/s or NS) I am much more concerned about complications than block success. The reason being is block success is pretty much expected no matter the technology being utilized.

Exactly!!!

But aren't your guys being a little hard on the youngster? He's just verbally regurgitating the BS he is being fed by his attendings.

 

[periopdoc]

but, but he is a pain fellow now (not that you could tell it from his prose).

Time to put on his big boy hat and think for himself.


**** if even Noy thinks that I am being to hard on him does that mean that I am headed for a time out?

- pod

 

[Noyac]

**** if even Noy thinks that I am being to hard on him does that mean that I am headed for a time out?

- pod

yesterday maybe, but we are in a better place here these days. It's like the wild wild west and the sheriff has been capped.

 

[periopdoc]

Great, now I can say things like

****

****



Hmmm, well I guess not.

- pod

 

[pgg]

yesterday maybe, but we are in a better place here these days. It's like the wild wild west and the sheriff has been capped.

Only a flesh wound!

Great, now I can say things like

****

****

Hmmm, well I guess not.

It'll star out your SDN password too. Here's mine

******

See? 😉


(Naughty words have never been offenses here.)

 

[Noyac]

(Naughty words have never been offenses here.)

F*ck that ****,

I guess the only thing offensive here is the moderation.

 

[Per4mer8]

I think it's a tad ironic that on the very day Jet is supposed to be back Blade starts a thread that is, in essence, the exact same thing that got Jet put on hold (allegedly).... Weird.

 

[Noyac]

I think it's a tad ironic that on the very day Jet is supposed to be back Blade starts a thread that is, in essence, the exact same thing that got Jet put on hold (allegedly).... Weird.

Maybe the FM mod Smq123 can talk PGG into putting Blade on a post-hold.

 

[pgg]

I think it's a tad ironic that on the very day Jet is supposed to be back Blade starts a thread that is, in essence, the exact same thing that got Jet put on hold (allegedly).... Weird.

Well again we don't comment on moderating actions ...


But I will say, unequivocally, that there is nothing actionable about a debt thread and how debt makes another specialty a poor choice, if it's not posted in that specialty's forum by a member of another specialty. It is not OK to head into another specialty's home forum and start ****, however well-intentioned it may be.

If you cruised over to the pyschiatry forum and started a thread about how they're wasting their degrees on some pseudoscience residency of handwaving, you'd be warned and the thread locked or dumped into the Lounge. If you posted the same thread here, it would stay open.

It's the same general policy that gives us a free hand to warn/infract/ban any midlevel who comes in here and starts **** about CRNAs. Midlevels are welcome on SDN, and there are places they can post those CRNA=anesthesiologist threads, but they can't do it here.

Maybe the FM mod Smq123 can talk PGG into putting Blade on a post-hold.

She could not. But it would never occur to smq123 to ask me such a thing in the first place.

 

[BLADEMDA]

I think it's a tad ironic that on the very day Jet is supposed to be back Blade starts a thread that is, in essence, the exact same thing that got Jet put on hold (allegedly).... Weird.

Not true. I never bash another specialty and think highly of Family Practice. The debt thread is simply a discussion of the ever increasing cost of a college plus medical school education in the U.S. it's an eye opener for me. Naturally, students with massive levels of debt may choose the more lucrative specialties. They don't need me to be Captain Obvious.

I rarely post anything on SDN outside our walls.

 

[Per4mer8]

Not true. I never bash another specialty and think highly of Family Practice. The debt thread is simply a discussion of the ever increasing cost of a college plus medical school education in the U.S. it's an eye opener for me. Naturally, students with massive levels of debt may choose the more lucrative specialties. They don't need me to be Captain Obvious.

I rarely post anything on SDN outside our walls.

Oh i know, there was definitely a difference in tact and delivery. It's still ironic.

I actually think it's great that someone of your stature (attending, and not a fresh out one at that) is interested in the plight of us lowly med students 😀. I am also hoping that thread morphs into a "how to get out from under that debt load and invest wisely" seminar that you are well suited to provide.....

And for the record I'm on the A4 side too.

 

[climbingak]

I don't think a pop fossa, or even higher at the convergence will help that much in an ACL with an auto hammy. Better to go infragluteal. The sciatic is deeper and may have to get the bigger probe, but not to hard to see at infragluteal. THe sciatic gets fuzzy in the middle ground between the bifurcation and infragluteal but usually with adjusting your wag you can see it. The closer to pop fossa the nerve is more visible if you aim the beam more distal. Closer to infragluteal can see it better when you aim the beam more proximal. I had a difficult time at first with US guided higher sciatics, but work at an ortho surgery center and after a few hundred have found the above to be true for me.

Sorry about the complication, real bummer. I hate the risk that goes along with these blocks that can be so good for the patient.

The ones that bug me are the few I have had that just have persistent mild tingling for a few days/weeks after the block. Full motor intact but just these weird funny feelings. I often feel it is the tourniquet cause it mostly happens on femoral or sciatic, but I have had one from an interscalene as well. Luckily all resolved relatively quickly and completely.

 

[BLADEMDA]

Let me share this with you: A few years ago I had a patient for a total knee replacement. Typical patient down here. Really old, everything wrong with him plus IDDM with peripheral neuropathy.

I knew this Ortho Surgeon inflates to 300 mmhg and has tourniquet times of 60 minutes. So, I skipped the Sciatic Block. I'm more cautious these days.

A week later the surgeon tells me "Blade you know that patient I did last week has a foot drop and I was wondering if your block could be the cause." I answered "Doctor I NEVER did a Sciatic Nerve block on that patient and the last time I checked a Femoral Nerve injury doesn't cause foot drop."

I found out that it took 6 months for that foot drop to get better and almost 2 years for full resolution.
This is another example of "blame anesthesia when anything goes wrong." No wonder so many Private practice guys simply avoid blocks.

U/S is no guarantee of safety. Yes, it helps medico-legally but don't think for one second they won't be blaming your block if anything goes wrong.

 

[fakin' the funk]

So I'll cut to the chase, there aren't any real twists here, but there are a couple other things worth talking about.

Nice post.